Homestead_Schultheis STATE FOP.M 53569(RI 1109) TREASURE(RRM TS-IA
APPROVED BY STATE BOARD OF ACCENTS.]D]9 PRESCRIBE)BY TIB:CEPARTSIEVT OF LOCAL GOVERHMEST FINANCE K 6-1.1-21-S I
. IMPORTANT NOTICE TO HOMESTEAD PROPERTY OWNERS :
Individuals and married couples are limited to one homestead standard deduction. As the receipt of this
deduction becomes more beneficial, there is more incentive than ever for homestead fraud. Homestead
•fraud causes higher tax bills for all; therefore, HEA 1344-2009 requires taxpayers who receive the
homestead standard deduction to verify that they are eligible to receive the benefit and to provide
additional indentifying information necessary to allow county government to better monitor homestead
filings. This information will be kept confidential and can only be accessed by authorized county officials.
The Department of Local Government Finance will use this information to create tools that will help
county officials eliminate homestead fraud.
PART 1: PROPERTY INFORMATION
Property Address(number and street,city,state,and ZIP code)
State Parcel Number
- IDo - wo t g ? 1 - oa4 FILE It
SEP 19 2013
4
• - PART 2:TAXPAYER INFORMATION
Owner First Middle Last
Mailing Address( ber and street,city,state,and ZIP code) - [J Same as property address
Fiirst Middle Last
Mailing Address(Number and street,city,state,and ZIP code) [] Same as property address
Social Security Number(last 5 digits) Driver's License/State ID Number (last 5 digits) Other(please specify in Part 4 below)
Slue
PART 3: CERTIFICATION
Each undersigned certifies,under penalty of perjury,that the above and foregoing information is true and correct and that he or she is
eligible to receive the homestead standard deduction on this property. Each undersigned also understands that, by claiming additional
homestead deductions unlawfully,he or she may be liable for back taxes and substantial financial penalties.
Owner I Signature Date
•
INSTRUCTIONS
MVP 05R e.
.�
ti�
y � CLAIM FOR HOMESTEAD PROPERTY TAX
' CREDIT/STANDARD DEDUCTION
\ ,• . � Statc Form 5473 (RS / 10-07 )
Prescribed by Ihe Department af lxal Gavemment Finance
INSTRUCTIONS: See reverse side /or filing instructions.
FORM YEAR
HC70
� � 9 e J � �
I(We) � certify thal .ihe tst day of M/ar!ch, 20
I(We) occupied as our principal piace o( sidence the following described real property for which a Homestead Pro ehy Tac C edit h6r by dai d:
�1 �e) awned ❑ Are buying under wn�ract GIBSON COUNT Y SUDI?0�
' Have a benefidal interest in Ihe entity that is liable for the property taxes on Ihe property and that owns ihe property or is buying under a wntrad.
II buying on wntrad. Fee Simple owners name
County
i( any
of the
:e whera conVad is recorded Record number Page
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To.mship T in d' Iritt iry, fown, township)
—%�� p� L d sc Uon Is Ihe praperry in question:
�`� p ❑ Real OroOerty ❑�MObile Homo (I.C. 61.7-n
f Ilie resitlenilal sWCture or the Wnd nol exceeding one (1) aae that immediately surtounds Ihat sWCture is used b produce income, desviba Ne use and poNOn
utiliZed tn produce inW me.
c�� - �� -/o? - /� - a 60• �7/-601 � ; .. .
20 _ Pay 20 _
Lesser of 1!2 Homestead
Valuation or $6,000
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S
Date s'gned
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